Electronic Records Foster Glucose Control

Action Points

These studies were published as abstracts and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

The use of electronic medical records (EMRs) for insulin order sets can improve glycemic control in hospitalized diabetes patients.

Note that the number needed to treat to prevent one episode of hypoglycemia was 17, and the number needed to treat to increase euglycemic episodes by one was 24.

PHILADELPHIA -- The use of electronic medical records (EMRs) for insulin order sets can improve glycemic control in hospitalized diabetes patients, researchers said here.

The rate of hypoglycemia pre-EMR subcutaneous insulin order sets was 9.6%, which dropped to 3.8% after the adoption of an EMR, according to Karla M. Arce, MD, from the Cleveland Clinic Florida in Weston, Fla., and colleagues.

The difference was significant at P=0.03 (95% CI 0.27 to 0.51), Arce said here at the American Association of Clinical Endocrinologists (AACE) meeting.

She noted that poor glycemic control in hospitalized patients is associated with worse outcomes. In particular, patients with hypoglycemia tend to have longer hospital stays.

Also, patients with sepsis, liver disease, renal insufficiency, bacteremia, and the elderly have a higher mortality rate if they are hypoglycemic.

But it's a balancing act to maintain tight glycemic control without inducing hypoglycemia, she said, adding the "benefits outweigh the risks."

That's where the EMR comes in. An EMR can ensure accurate tracking of all orders during all phases of hospitalization. This help clinicians avoid duplicate orders or prescribing more than one medication from the same class.

In their study, Arce and colleagues retrospectively evaluated a randomly selected number of records of diabetic patients from 2007 to 2011.

At the Cleveland Clinic Florida, it also has reduced errors as far paper orders getting lost, Arce said. Having the order sets in the EMR affords better clarity for dosing and timing of insulin injection and gives specific orders on when to notify a physician for a low or high blood sugar.

â€œWhen we open the insulin order set, it shows which type of insulin to give, and also helps to choose which type of sliding scale to use depending on the total daily dose and weight of patients,â€ Arce told MedPage Today. â€œAnd because itâ€™s in the EMR, everyone sees and follows the same orders.â€

A total of 34 patients with 730 blood glucose values comprised a pre-EMR group and 222 patients with 2,967 blood glucose values comprised a post-EMR group.

Hypoglycemic readings were defined as less than 80 mg/dL, euglycemic as between 80 and 180 mg/dL, and hyperglycemic as greater than 180 mg/dL.

The post-EMR group had a significant 6% lower rate of hypoglycemia. Also, the rate of euglycemia was significantly greater in the post-EMR group (65% versus 60%, P<0.005, 95% CI 1.01 to 1.41), Arce reported.

Researchers found that the number needed to treat to prevent one episode of hypoglycemia was 17, and the number needed to treat to increase euglycemic episodes by one was 24.

"The development of insulin order sets and documentation tools has had a dramatic effect on decreasing the incidence of hypoglycemia, improving glycemic control, and increasing adherence to evidence-based practices," they noted.

In a second related study, Arce and colleagues retrospectively reviewed a random sample of 3,316 hospital records of patients who did not have an initial diagnosis of diabetes.

They found that 281 patients had blood glucose levels above 140 mg/dL, but only 10% were checked for hemoglobin A1c (HbA1c ) levels.

However, within this small group, 51% had diabetes and 20% were prediabetic, Arce reported.

"We understand that HbA1c testing in hospitalized patients has limitations," they noted. "However, we must recognize the importance of ordering it in selected patients with hyperglycemia to diagnose diabetes early and to be able to institute proper follow up and treatment to prevent complications."

Arce and colleagues observed that patients with newly diagnosed diabetes are at a greater risk of death compared with those with a history of the disease or normoglycemia.

"Obtaining HbA1c in a hospitalized patient with a blood sugar level above 140 is reasonable given the high sensitivity and specificity of sugar reading for detecting diabetes," they concluded.

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